Key words : Back-table preparation, Kidney transplantation, Organ preservation

Dear Editor:

Machine perfusion (MP) has revolutionized the field of kidney transplantation (KT). A large body of literature has supported its use in different situations, including graft reconditioning, evaluation, and long-term preservation.^1-6 With the increasing number of kidneys being placed in MP, transplant surgeons often encounter vascular abnormalities. Multiple renal arteries have been observed in approximately 30% of kidneys and are always “terminal” (ie, without overlap in their areas of supply), which mandates their systematic revascularization in the recipient.^7,8 For this reason, the commercially available MP devices offer various solutions to connect more than one artery, such as large clamps and multiple cannulas. Nevertheless, a bench reconstruction may be necessary. We do, however, believe that the decision to use MP should not condition the technique of vascular reconstruction.

Here, we present the case of a left kidney with 3 similarly sized arteries (6-7 mm in diameter), which was offered to our center for transplantation. The donor was a 54-year-old male who was pronounced dead due to anoxic brain injury, with no history of diabetes or hypertension and serum creatinine level of 0.8 mg/dL (Kidney Donor Risk Index: 0.86). We decided to use MP to postpone the KT due to an ongoing emergency in the operating room. The Carrel patch was of good quality (Figure 1A and 1B) but too long to be included in the largest commercially available clamp (10 × 25 mm). Patch shortening by dividing the intervening segments and suturing the 3 arterial orifices together would have involved additional sutures, and the shortened patch would still not have easily fit the clamp. Single arterial cannulation could have possibly resulted in intimal damage at the site of securement, making the Carrel patch unusable for subsequent implantation. In addition, an end-to-side anastomosis of the 2 lateral arteries to the central one would have involved a relatively complex reconstruction and additional sutures.

Therefore, during back-table preparation, we anastomosed the Carrel patch containing the 3 arterial orifices to an iliac arterial graft recovered from the same donor. After ligating the stump of the internal iliac artery and the terminal end of the graft, we connected it to the Waves MP device (Institut Georges Lopez, Lissieu, France), as shown in Figure 1C. Perfusion time and total preservation time were 22 hours and 32 hours, respectively. Renal resistance held steady during perfusion (0.24-0.21 mm Hg/mL/min). The recipient was a 45-year-old male patient with chronic glomerulonephritis who started hemodialysis 3 years earlier. The kidney was implanted on the right external iliac vessels using the same Carrel patch after the bench reconstruction was dismantled. The postoperative course was uneventful, with immediate graft function and no complications after a 1-month follow-up.

This unusual but simple technical solution allows the surgeon to connect the kidney to MP without refraining from the use of the classical Carrel patch anastomosis, even in cases of multiple large-caliber renal arteries, and could be a valuable addition to the transplant surgeon’s armamentarium.

References:

1. Haberal M, Oner Z, Karamehmetoglu M, Gulay H, Bilgin N. Cadaver kidney transplantation with cold ischemia time from 48 to 95 hours. Transplant Proc. 1984;16(5):1330-1332
   CrossRef - PubMed
   
2. Haberal M, Karakayali H, Moray G, et al. Cadaveric kidney transplantation: effect of cold ischemia time and HLA match. Transplant Proc. 1999;31(8):3336-3337. doi:10.1016/s0041-1345(99)00816-7
   CrossRef - PubMed
   
3. Haberal M, Sert S, Aybasti N, et al. Cadaver kidney transplantation cases with a cold ischemia time of over 100 hours. Transplant Proc. 1987;19(5):4184-4188
   CrossRef - PubMed
   
4. Jochmans I, Moers C, Smits JM, et al. The prognostic value of renal resistance during hypothermic machine perfusion of deceased donor kidneys. Am J Transplant. 2011;11(10):2214-2220. doi:10.1111/j.1600-6143.2011.03685.x
   CrossRef - PubMed
   
5. Ekser B, Chen AM, Kubal CA, et al. Delayed kidney transplantation after 83 hours of cold ischemia time in combined liver-kidney transplant. Transplantation. 2019;103(11):e382-e383. doi:10.1097/TP.0000000000002673
   CrossRef - PubMed
   
6. Bellini MI, Nozdrin M, Yiu J, Papalois V. Machine perfusion for abdominal organ preservation: a systematic review of kidney and liver human grafts. J Clin Med. 2019;8(8). doi:10.3390/jcm8081221
   CrossRef - PubMed
   
7. Satyapal KS, Haffejee AA, Singh B, Ramsaroop L, Robbs JV, Kalideen JM. Additional renal arteries: incidence and morphometry. Surg Radiol Anat. 2001;23(1):33-38. doi:10.1007/s00276-001-0033-y
   CrossRef - PubMed
   
8. Mohamed T, Sequeira-Lopez MLS. Development of the renal vasculature. Semin Cell Dev Biol. 2019;91:132-146. doi:10.1016/j.semcdb.2018.06.001
   CrossRef - PubMed